The SAVE Act: Voter Suppression as Health Policy

You may be aware that the Senate is continuing its consideration of the abysmal SAVE Act, but you may not realize the critical ways that this legislation operates as a political determinant of health – and the health of American patients is on the line.

As a health policy professor, I often talk with my students about social determinants of health, or the array of non-medical factors (e.g., education, poverty, environment, housing) that profoundly affect our health. In fact, while medical care accounts for 10-20 percent of our overall health, social determinants account for the remaining 80-90%! In fact, this helps to shed light on why America’s exorbitant health spending has such a poor return on investment in terms of health outcomes: we concentrate our investments on the health care side of the equation while spending comparatively less on social supports. The result is something akin to pouring water down an open drain: we have the investment (the water) but we can’t build the reserve.

Of course, budgets reflect political values and America’s underinvestment in its safety net (well, more recently, its hollowing out of its safety net) is the product of intentional political choices. But there are also an array of political choices – from gerrymandering to dilute political competition to campaign finance laws that can allow corporations to drown individuals’ political voices to laws directly taking aim at voting rights – that fall under the umbrella of political determinants of health, or the political decisions that drive health access and outcomes by reshaping the strength (or lack thereof) of political representation and whose interests are advanced on Election Day.

U.S. voter turnout already lags in comparison to many OECD countries, and there are notable participation gaps along race and class lines, as well as health lines: people in poor health are less likely to vote. And this health bias can be recursive because politicians have more incentive to be responsive to higher-propensity voters, which can perpetuate policies that exacerbate health-voting participation gaps.

This is a problem. It is hardly surprising that someone who has lived experience with Medicaid or SNAP, or whose health is otherwise in the crosshairs in moments of proposed health reform, would have a vested interest in the election of a certain type of candidate who might differ from the preference of someone who is healthy, has not had to navigate public programs, and consequently may see less value in raising taxes to invest in programs that promote equitable access to health care. Political scientist Jamila Michener’s Fragmented Democracy illustrates beautifully, albeit painfully through administrative data and interview-based evidence the salience of the intersection of health, poverty, and feelings of political disempowerment that can all too often be self-reinforcing. And a report by The Century Foundation found that non-voters are more supportive of expansions of the safety net… but until they turn out on Election Day, their voices are muted.

Which brings us to the SAVE Act.

Let’s start with disabusing ourselves of the misguided notion that widespread voter fraud is a problem in American elections. It’s not. Comprehensive analysis by election law scholar Justin Leavitt found that among nearly a billion votes cast between 2000 and 2014, there were just 31 credible cases of voter fraud.

Not 310,000. Not even 31,000. 31.

The Brennan Center for Justice compiled a number of other studies, estimating (for example) that the upper bound on double voting was 0.02% (though likely much lower), the absence of widespread voter impersonation, and just 30 cases of suspected noncitizen voting from among 23.5 million votes cast. Even the conservative think tank The Heritage Foundation, which orchestrated Project 2025, found only a miniscule number of credible cases of voter fraud. And when we consider the odds of being a pivotal voter, even as I write this in Pennsylvania, it is little wonder why comedian John Oliver compared the value of voter fraud to risking criminal penalties to forge a Bed, Bath & Beyond coupon.

I’d say that voter ID laws are a solution in search of a problem, but they’re really a solution to a different problem: people of color having the temerity to participate in the democratic process, and those seeking to suppress these votes are gallingly doing so with the blessing of the Court majority led by John Roberts in Shelby County v. Holder. And while most people do have a form of government-issued ID, it is neither universal nor costless to obtain, whether taking into account the direct costs (it costs $45.50 to get an initial driver’s license in Pennsylvania) or opportunity costs of the time and effort to obtain it, which may bring into the picture social determinants of health barriers (e.g., if the office is not accessible via public transportation). Not only do nearly 29 million U.S. citizens lack a non-expired driver’s license, but 7 million lack any other form of government-issued photo ID. And of course, non-possession of a government-issued ID is unevenly distributed, with Black and Hispanic, less affluent, and lower educational attainment individuals especially unlikely to have a current ID, with the potential result that there will be further inequities in ability to exercise the constitutionally protected right to vote.

But as if these inequities weren’t bad enough, the SAVE Act is not an ordinary voter ID law. It does not compel the provision of a state ID or driver’s license, but rather proof of citizenship in the form of a passport or driver’s license.

Not only do only about half of Americans have a passport, but there is marked geographic variation, ranging from 20.7% (West Virginia) to 79.9% (New Jersey), raising the notable irony that this policy would exacerbate administrative burdens the most in red states. (The states with the lowest rates of passport possession are West Virginia, Mississippi, Alabama, Arkansas, and Kentucky.)

So, you don’t have a passport. That can be remedied, right?

Yes, but it’s not so simple. The cost of a first-time passport book is $130, which is a nontrivial price tag and arguably a poll tax by another name. (Remember, poll taxes didn’t cost an arm and a leg – around $35 in today’s currency – but the way that they were administered were strategically prohibitive barriers, ultimately giving rise to the 24^th Amendment.) What’s more, poor health and poverty can be bidirectional: not only do illness and disability make it harder to sustain gainful employment, potentially trapping people in poverty conditions, but as anyone who has had to choose between groceries and prescriptions (or had to remove things from the conveyor belt as costs add up) can tell you, the stresses of economic precarity take a toll on physical and mental health, reinforcing this constellation of hardships.

And let’s think about the logistical process of obtaining said passport, and the administrative burdens therein. One must fill out a form online and print it (assumptions: home broadband and possession of a printer). One must have evidence of citizenship in the form of an original birth certificate or a full validity, undamaged passport (assumption: possession of an original copy of one’s birth certificate). One must obtain a government-issued photo ID – or two, if one’s ID is from another state (assumption: possession of a government-issued photo ID, which as discussed above is not costless to obtain). And one must print a high-resolution recent color photo, which may require a trip to get a passport photo taken.

Now imagine doing all of this when feeling physically or mentally unwell. Or being disabled. Or juggling medical appointments and other responsibilities.

Administrative burdens can impede access to many benefits to which people are entitled. One need look no further than Medicaid work requirements, which led 18,000 Arkansans to lose Medicaid coverage despite working or being exempt. And I have worked to show that red tape can impede access to health benefits because even though appeal processes are in place when barriers arise, less affluent patients don’t appeal as often, and sicker and Black and Hispanic Medicaid patients tend not to prevail as often. While burdens can be felt throughout the population (you’d be hard-pressed to find someone who enjoys schlepping to government agency offices and filling out long and complex forms), these burdens are often felt disproportionately by those who are living on the margins – whether living paycheck to paycheck, lower health literacy and administrative capital, or battling health conditions that at once raise the costs borne by patients as well as the stakes of being unable to fulfill bureaucratic directives.

All told, researchers at the Brennan Center estimated that 9 percent of voting-age American citizens lack proof of their citizenship and would be disenfranchised under the SAVE Act – whether because their documents are in someone else’s possession (e.g., their parent has their birth certificate) or because their documents were lost, destroyed, or stolen. Notably, they state that this is likely a conservative estimate and unsurprisingly, there are racial inequities, such that America would witness worsened voting participation gaps and poor substantive (and likely descriptive) representation for those from historically underrepresented groups, which also happen to be on average in worse health.

So, what we’re left with is a bill that is blatant voter suppression poorly cloaked in concern about election integrity, imposing senseless financial and administrative burdens that are facially neutral toward U.S. citizens but which are felt most acutely by racial and ethnic minorities, those who are lower-income or who have less educational attainment, and who experience disability and health conditions that raise the costs of compliance with these new and senselessly onerous terms – all to exercise an ostensibly constitutional right as opposed to a policy benefit. It is a poll tax by another name and must be treated as such.

And what happens when those in power are not facing voters who are bearing the costs of their misguided health polices? When the electorate that is not simply eligible in theory, but capable of voting in practice has never felt the pinch of rising health care costs or the strain of navigating health-related administrative burdens? Lived experience matters. It can help to shed light on policy defects that were unanticipated. It can elevate the importance of putting issues on the legislative agenda. And without it, policy runs the risk of being poorly delivered (whether intentionally or inadvertently) to the target population, and patients suffer. Demands for health reform do not accrue, or do not resonate. Feelings of political disempowerment become validated and persist. Rinse, repeat. E.E. Schattschneider’s famous conceptualization of “a new policy creates a new politics,” but the health policies that emerge from these feedback effects run the risk of systematically leaving key populations behind.

Infuriatingly, this is a feature, not a bug. And unlike many other domains of failed policies, by reshaping the contours of the American electorate, it would be an especially difficult one from which to reverse course.

The SAVE Act has garnered ample support thanks to a good old fashioned American combination of ignorance, racism and xenophobia, and cowardice in the face of threats of primary challenges from the most conservative segments of the Republican Party.

Concern will not help the patients who become governed by politicians who do not have health care interests in mind.

Concern will not help salvage what is left of the American democratic process when voting rights are put in a shredder.

And rest assured, concern will not spare the political careers and legacies of politicians whose cowardice dominates fidelity to the Constitution.

If we care about health, equity, and the integrity of American voting, it is imperative that we recognize the SAVE Act for what it is: a deliberate effort to narrow whose voice counts in America. It is a war against democracy, and a war against public health.

Call your members of Congress to oppose the SAVE Act. 202-224-3121.